# 一位術後個案已8小時未排尿，並主訴下腹部不適。護理師應首先採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394133&lang=zh-tw  
> language: zh-TW  
> subject: Elimination  
> category: BCC

## 題目

一位術後個案已8小時未排尿，並主訴下腹部不適。護理師應首先採取哪項行動？

## 選項

1. 在剩餘的班別中限制液體攝入。
2. 評估膀胱膨脹，並根據方案進行膀胱掃描。 **✔ 正確答案**
3. 告知個案尿滯留是預期現象，無需採取行動。
4. 永久放置留置導尿管。

**正確答案: 2**

## 解析

術後尿滯留應立即評估。護理師應在進一步介入前，評估膀胱膨脹並根據方案使用膀胱掃描。永久放置導尿管並非首要行動，且會增加感染風險。

## 深入解析

臨床判斷
尿滯留是舒適、腎臟和感染預防的問題；在採取侵入性措施前先進行評估。

記憶提示
未排尿加上不適：掃描膀胱。

## 臨床情境

臨床實務指引
術後排泄照護包括攝入/排出量、膀胱評估、疼痛控制、活動，並盡可能避免使用導尿管。

注意事項
未處理的尿滯留可能導致膀胱過度膨脹。

## 重要概念

- **尿滯留** — 無法充分排空膀胱。
- **膀胱掃描** — 一種非侵入性超音波，用於估算膀胱內的尿液量。
- **膀胱膨脹** — 因尿液滯留導致的膀胱擴張。

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